DISCUSSION QUESTIONS 1. Do you anticipate any additional challenges or barriers?

2. Are there other solutions to the issues identified?

3. How can we get buy-in for engagement in these recommendations?

4. What needs to be changed in order to fill the large gap in post-active treatment care?

5. How can we best use social media to promote outreach?

6. What opportunities for funding might be available?

HUTCHINSON INSTITUTE FOR CANCER OUTCOMES RESEARCH / fredhutch.org/HICOR

BREAST CANCERSURVEILLANCE

VISION STATEMENT: Post-active treatment is an integral part of breast cancer care. This care supports patients’ physical and emotional well-being and is delivered by knowledgeable, competent, and caring providers who are experienced in the unique post-active treatment symptoms and needs of cancer patients.

INTERVENTION WORKING GROUP

INTERVENTION PROPOSAL

BENCHMARKING

To intervene on provider-

driven testing

To intervene on patient-

driven testing

Repeated measurement of compliance with guidelines allows for measurable improvement as systems and provider behaviors change.

POST-ACTIVE TREATMENT CAREImplement a comprehensive post-active treatment care program to address the specific needs that patients experience at this time.

PROVIDER EDUCATIONProvide clinicians with a robust provider/patient guideline instruction set.

Issue to address: There is often a gap between the provider’s perceived and actual behavior.

Issue to address: Post-active treatment care is a pivotal time for cancer patients, however it is frequently not prioritized or integrated as a part of overall care. There is a need for patient information and clinical resources after active adjuvant treatment ends to help patients manage the side effects of cancer treatment.

Issue to address: Medical care is a collaboration between provider and patient. Providers must balance the weight of medical literature and the individual needs of their patients. Guidelines are developed to help evaluate current evidence, but providers may not be aware of them, or may not know how to apply them to the exact conditions of their patient.

HUTCHINSON INSTITUTE FOR CANCER OUTCOMES RESEARCH / fredhutch.org/HICOR

BREAST CANCERSURVEILLANCE

INTERVENTION WORKING GROUP

IN DEPTH

Issue to Address: Gap between provider’s perceived and actual adherent behavior

Benchmarking

• HICOR IQ can provide clinics and providers with current utilization rates on Choosing Wisely guidelines

• Determine benchmark goals

• Once results are shared, provide support to facilitate improvement (resources, education, institutional solutions)

• Oncology clinics

• Providers

• Medical directors

• Clinical administration

• Information technology

• Payers

• Solicit feedback from providers

• Support clinics in tailoring benchmarking process to their needs and propose possible incentives

Develop targetededucational tools

• Readily available PowerPoint presentation

• Emails/letters and brochures

• Signal in EMR

• Online education

Conversation should emphasize

• Goal is appropriate utilization

• Focus on routine testing for asymptomatic patients

• Guidelines may evolve as evidence does

• Frame question: Will results change my course of action as the provider?

Audience

• Target PCPs and oncologists

Key targets

Within clinic:

• Breast tumor board

• Clinical meetings

• Grand Rounds

Larger associations:

• WA Academy of Family Physicians

• American College of Physicians

• WA State Medical Oncology Society

• WA State Medical Association

• County-based medical associations

• Develop or modify existing educational materials

• Partner with local clinics for educational opportunities

• Partner with established online education forums

BENCHMARKING

PROVIDER EDUCATION

Intervention Key Stakeholders How to Move Forward

Issue to Address: Provider non-adherence

Intervention Key Stakeholders How to Move Forward

BENCHMARKINGTo intervene on

provider-driven testing

To intervene on patient-driven testing POST-ACTIVE TREATMENT CARE

PROVIDER EDUCATION

HUTCHINSON INSTITUTE FOR CANCER OUTCOMES RESEARCH / fredhutch.org/HICOR

INTERVENTION WORKING GROUP

Issue to Address: For cancer patients, the post-active treatment period can be a confusing and stressful time as care may transfer without clear, effective mechanisms for communication and coordination. Issues that are frequently unclear or not explicitly stated include: when a patient should see their oncologist; how a PCP cares for complex symptoms; who a patient should go to for which symptom; and who is coordinating the patient’s care.

POST-ACTIVE TREATMENT CARE

POST-ACTIVE TREATMENT CARE: PROVIDER FOCUS

Active collaboration between oncologist, PCP, survivorship clinic and patient during transition to post-active treatment care should include:• Treatment Summary• Clear plan to transition care between oncologist to PCP and/or survivorship clinic • PCP/patient education about “red flags” or concerning symptoms to observe• When and how the PCP or patient should contact the oncologist• Most important information the PCP should know about the patient• Template of Treatment Summary in IT/EMR• Communication about risk of recurrence

• Identify compensation streams for coordinated, evidence-based, post-active treatment care• Develop a system that facilitates communication between oncologists and PCPs across systems/provider groups• Create tools for transitioning care • Emphasize that time constraints render provider education and communication resources critical• Work with IT to integrate Treatment Summary tools into EMR• PCP training and education in post-active treatment symptoms

• Partner with oncology clinics, PCPs, and survivorship clinics to develop plan of action• Research possible funding streams

Intervention Implementation How To Move Forward

POST-ACTIVE TREATMENT CARE: PATIENT FOCUS

• Patient Voices Series: patients write their stories • Oncologist to review • Partner with advocacy groups • Utilize social media

• Post-active treatment symptom guides • 1-yr (transitioning care) • 5-yr (long-term effects) • 10-yr (late, long-term effects) • Differentiate between symptoms from treatment vs. signs of recurrence

• Identify medical contact(s)• Clinic or single medical contact for post-active treatment care• Provider who supports patient through transition from oncology to PCP or next level of care• Provider who specializes in cancer care• Funded as a part of cancer care

• Compile resources

Information Campaign Self-Symptom Management Tools Clinic or Single Medical Contact Index of Resources

BREAST CANCERSURVEILLANCE IN DEPTH

BENCHMARKINGTo intervene on

provider-driven testing

To intervene on patient-driven testing POST-ACTIVE TREATMENT CARE

PROVIDER EDUCATION

HUTCHINSON INSTITUTE FOR CANCER OUTCOMES RESEARCH / fredhutch.org/HICOR

INTERVENTION WORKING GROUP

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CURRENT GUIDELINES

CONSENSUSThere is an overall gap in care and resources for both providers and patients, as cancer patients transition out of adjuvant treatment and into the post-active treatment period. A comprehensive post-active treatment program can support patients through the very real physical and mental challenges that follow cancer treatment.

KEY POINTS• Initial focus on ASCO Choosing Wisely Guideline 4, which outlines recommendations for surveillance testing and imaging, was broadened to encompass overall post-active adjuvant treatment care.• System, provider, and patient-level factors drive the use of tumor markers and advanced imaging during post-active treatment care. • Providers may order tests due to lack of awareness of the guidelines and/or their own adherence to guidelines.• The lack of post-active treatment care may be a driving factor for patients requesting testing.

“Post-Active Treatment” refers to the time after active adjuvant treatment ends; patients on hormone therapy are still considered post-active treatment. The American Cancer Society (ACS) and the American Society of Clinical Oncology (ASCO) term this period “survivorship.”

WORKING GROUP PURPOSEDesign intervention protocol(s) to improve the appropriate use of tumor markers and advanced surveillance imaging in women with early-stage breast cancer treated with curative intent.

BREAST CANCERSURVEILLANCE CONTINUED